MEDICARE: DR. KIMBERLY A BALOG MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	3085908-1205	UT

General Provider Information

NPI Number	:	1891777587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIMBERLY A BALOG MD

Provider Business Mailing Address
First Line	:	2 BIRCHTREE LN
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84092
Country	:	US
Telephone Number	:	801-523-0761
Fax Number	:

Provider Business Practice Location Address
First Line	:	1255 EAST FORT UNION BLVD
Second Line	:	SUITE 200
City	:	MIDVALE
State	:	UT
Zip	:	84047
Country	:	US
Telephone Number	:	801-523-0761
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2005
Last Update Date	:	07/08/2007

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